Addition and subtraction – Kevin Lewis does the maths

on 2 April 2008

Here, Kevin Lewis bemoans the prospect of yet more forms to fill in for baffled practitioners…

Two down, one to go. Years, that is, until the end of the transitional protections that came as part of the nGDS package in April 2006.

The new-style FP17, and the new mandatory dataset that it will be used to collect, is as significant for what has been left out, as for what has been included, but it contains more than enough information to arm the PCTs with the ammunition needed in order to justify changes in UDA values next year.

This is good news for some and unwelcome news for others. The UDA has come to be viewed as a currency with all the credibility of the Zimbabwean Dollar. Because it had never been tested prior to implementation – despite the availability of the Options for Change fieldsites which had spent two-to-three years trying out just about every option except the one which was eventually introduced – it was intended to do something for which it was ill-equipped.

UDAs have never actually measured activity at all (other than in the clumsiest sense), nor quality of care. They were silent on the detail of what was actually being done, and how often, and on the balance between prevention and intervention.

Practitioners will, as from this month, be required to state how many teeth they have filled, or root filled, or fissure sealed, or crowned etc – over and above the ‘headline’ Band One/Band Two/Band Three categorisation. The requirement to state how many teeth are being replaced on a denture, and whether it is acrylic or metal in construction, provides no meaningful clinical information because there is no baseline data on how many teeth are present in the patient’s mouth.

But this, and the information on the crowns, veneers, bridges provided, will re-establish some ‘ballpark’ data on the laboratory expenses that are being incurred which can be set against the UDAs being generated and the fees being paid to the provider.

For the last two years, 12 UDAs for a Band Three course of treatment have justified a payment in the region of £250-£300 to a ‘average’ provider (although less than £200 for many and more than £350 for some). The associated laboratory fee could take a bite of varying proportions out of this, from 20% or less, up to 100% or more.

Those in private practice who have not lived in this parallel universe will be wondering how many crowns a dentist might do for £250 or £300 (or less), and they will be reassured to know that you would not normally expected to crown more than 32 teeth for this sum. The NHS is nothing if not fair and reasonable. The new clinical dataset will not necessarily be welcomed, even by those working in areas of socio-conomic deprivation and having to spend several visits on most of their ‘Band Two’ excursions in search of three UDAs.

It will provide the hard evidence of the time that they are having to spend on the swings and roundabouts, which is no bad thing, but it will also confirm if, when and where they spend any time on the dodgems to balance the books.

Apologies for absenceIs there a box to indicate how many visits the patient has failed to attend? Or a box to indicate how much of the practitioner’s time has been wasted through the atient’s non-attendance? Or a box to indicate how much time the practitioner is spending talking to the patient or giving preventive advice, or providing nformation on oral or general health promotion, or smoking cessation? Of course there isn’t – from which you can draw your own conclusions about what the form is designed to achieve.There isn’t enough space to include everything, of course, and no doubt it will be argued that this is why certain things have been selected to include on the form, while other things have been omitted – it is a question of priorities.

All the more interesting, then, that so much data is being gathered on Exemptions and Remissions (with two menus of no less than 11 boxes each for the patient and dentist respectively to select from). The dentist who signs the FP17 in order to claim the relevant UDAs is stating that he or she has seen the relevant documentation to provide Evidence of Exemption from patients charges, and if turns out that no such evidence exists, the dentist is liable to be asked to confirm precisely what evidence was seen.

Gone are the days of accepting what the patient tells you on trust, although the patient is duly warned of the consequences of making an incorrect statement, and in cases where the evidence is requested by the dentist or practice staff, but is never actually produced by the patient, there is an all-important ‘Evidence of Exemption or Remission not Seen’ box to cross.

This is not new, of course, but the crackdown on NHS Fraud did not fade away when fee-per-item was removed.

The NHS is known to lose bucketloads of revenue from patients who claim to be exempt from NHS dental, optical and pharmaceutical charges when they are actually liable to pay the charges. What is less obvious from the FP17 design, is the current scrutiny of cases where patients are actually paying charges, even though both declarations (i.e. on the part of the dentist and patient) on the FP17 show the patients as being exempt.

These anomalies are picked up through complaints, or through patient surveys of which the treating dentist is unaware.

Further examples of a conscious decision about what to keep in, and what to leave out of the form design, are the 16 ‘ethnic group’ options from which the patient is invited to choose, and the ‘In prison or Young Offenders Institution’ option (referring to the patient, not the dentist, I presume).

These are overtly included to collect data on the oral health, attendance patterns and treatment needs of these groups of patients, but there is no attempt to re-introduce any means of collecting longitudinal data on the longevity of restorations.

Long-suffering reception staff in NHS dental practices must groan at the prospect of yet another new form. Dental software companies are enjoying a brisker trade than dental laboratories these days, but even when the FP17 data is collected and transmitted electronically, it is worth remembering that the ‘official’ dataset is collecting (for the most part) the evidence for the prosecution.

In many instances practitioners will need to be collecting and storing further data over and above the new NHS dataset in order to strengthen the case for the defence, and/or to fend off clawbacks or to argue for better UDA values than the PCT might be minded to offer.